ASRS CALLBACK includes excerpts from ASRS incident reports with supporting commentary. In addition, CALLBACK may contain summaries of ASRS research studies and related aviation safety information. CALLBACK is one of the ASRS's most effective tools for improving the quality of human performance in the National Aviation System (NAS) at the grass roots level.

Monday, July 15, 2013

CALLBACK 402 - July 2013


CALLBACK From the NASA Aviation Safety Reporting System
Issue 402
July 2013
Crossed Wires in Maintenance Procedures
“Crossed wires” or “crossed signals” are colloquialisms often used to indicate confusion or misunderstanding in everyday conversation. When it comes to aircraft maintenance, however, crossed wires or other crossed connections may refer to actual errors in the placement of components or wiring. The following ASRS reports from Maintenance Technicians deal with aircraft components that have been improperly installed, leading to unexpected and unwanted results.
Backwards Brakes: Crossed Hydraulic Lines
Two Maintenance Technicians reported on their involvement in a BE-400 brake procedure that resulted in a gate return for the aircraft. The Flight Crew discovered that the left pedal controlled the right brake and the right pedal controlled the left brake.
Technician #1
I was assigned the Anti-Skid Control Valve Union Filter Cleaning Task Card on a BE-400 aircraft. I performed the task in accordance with the Maintenance Manual. When I was reinstalling the lines, I mixed up the aft hydraulic pressure lines to the valve. The lines were not hard to install this way and the installation seemed right to me. I had my Lead Mechanic buy-back (verify) the work. We ended up job-stopping the task, with the Brake Bleeding and Anti-Skid Control Checks still needing to be accomplished.

The lines got mixed up even though they were tagged. I could have taken a picture of the valve before I started the task. This would probably have prevented the lines from being installed wrong because I would have referenced the Maintenance Manual and the picture. The Anti-Skid Brake System Check in the Manual says to push both brakes at the same time during the check. A revision to the Manual that would require each brake to be checked individually and verify proper operation probably would have caught the problem in maintenance. The repair station could also adopt a policy of requiring a run/taxi after brake maintenance procedures.
Technician #2
It was reported to me that a BE-400 aircraft had an issue with the brakes…. The right pedal controlled the left brake and the left pedal controlled the right brake. I was also told that the power brake anti-skid control valve lines had been installed to the wrong fittings during the power brake anti-skid control valve filter change.

I was involved in doing the [brake] bleeding procedure and anti-skid system test. Prior to us starting the procedures, all the equipment was already set up for us and all the steps seemed to have been performed as stated in the manual. It would not have even occurred to me that the brake system could operate backwards….

The hydraulic lines and valve connections should be permanently marked to ease the proper installation process.
Hot Brakes: Confused Color Codes
An A-320 Maintenance Technician reported mistaking a Yellow system hydraulic line hose coupling for a Green system hydraulic coupling resulting in an improper MEL deferral.
Following troubleshooting procedures to determine the cause of a brake overheat, I determined that the anti-skid system was possibly not managing the brakes which was causing an overheat and not just a temperature reporting error. Maintenance Control agreed with my explanation allowing the deactivation MEL and subsequent procedure.

After retrieving the exact Maintenance Manual reference for deactivation, I entered it into [the computer] which displayed several subtasks. One of these was a specific procedure for deactivating only the Green, normal side. I chose this based on the previous Troubleshooting Manual task for complying with the Normal Brake System Tachometer Functional Test. The Troubleshooting Manual was referencing only the Green normal system with a possible fault. I misidentified the Green system and the Yellow system. Had I removed the correct hydraulic line, the brake would not have activated even though one side was disconnected and stowed. Since the brake was still active, the high temperature condition reoccurred upon landing. I was working on the Normal braking system so I decided to only deactivate that side, but confused the yellow and green hydraulic hose couplings….

The MEL reference for the deactivation procedure should be updated to read the exact subtask that will link directly to deactivating the entire brake. Currently, when this task is entered, several other deactivation choices appear.
Faulty Fire Extinguisher: Crossed Wires
In this ERJ-170 Maintenance Technician’s report, crossed wires didn’t actually cause the problem, but they certainly contributed to it. The ability to cross two electrical connections in order to attach them to the corresponding engine fire bottle cartridges disguised the fact that the cartridges were actually installed backwards.
While performing the Fire Bottle Job Card, referencing the Aircraft Maintenance Manual, it was discovered that the fire bottle cartridges were installed in the incorrect locations allowing the left engine fire extinguishing agent to be discharged to the right engine and the right engine fire extinguishing agent to be discharged to the left engine in the event of an engine fire. This bottle had been installed on the aircraft [in this configuration] for several years. To compound the issue, the wiring on the aircraft has sufficient slack to allow the [electrical] connectors to also be installed incorrectly [to their matching cartridges] and the Maintenance Manual Task to replace the bottles and cartridges is not clear enough to prevent incorrect assembly.

The aircraft is assembled in a manner in which cross-connection of the electrical connectors for both the “A” and “B” engine fire bottles is possible. In a worst case scenario, if both bottles are affected, neither engine would have fire protection….

There is no labeling on fire bottles “A” or “B” identifying the left or right engine squib cartridge positions. The bottles are identical, interchangeable, have the same part numbers, and come new from the manufacturer or overhaul vendor with the squib cartridges and discharge nozzles already installed. Two discharge nozzle outlets are screwed into each fire bottle, they use a common thread, are interchangeable, and they can be installed on either fire bottle. There are two different part numbers. Two nozzles have coarse-threads and the other two nozzles have fine-threads that will only accept a specific squib with similar threads. There are also two different part numbers for the four squibs; two with coarse threads and two with fine threads. The electrical connectors are also keyed to a similar squib.

The wiring harnesses should be shortened, or zip-tied to prevent an electrical connector meant for bottle “A” from reaching bottle “B.” The wire harnesses are routed to the fire bottles from different directions. The maintenance procedure should also be rewritten to emphasize the correct installation of the connectors.

The aircraft involved had gone through at least one C-Check without the discrepancies being noticed.
Hydraulic System Blues: Crossed
Pressure Lines
While trouble shooting the cause of two previous replacements of an A-319’s hydraulic system reservoir pressurization manifold, a Maintenance Technician found that “criss-crossed” pneumatic pressure lines were preventing pressurization of the Blue hydraulic system.
After discovering that we were going to install [an A-319’s] hydraulic reservoir pressure manifold for the third time, I decided to figure out why the…manifolds were not pressurizing the Blue hydraulic reservoir to 50 PSI. After a few hours of troubleshooting the problem, I found that the left engine [pneumatic] supply line in the left wheel well…was connected to a “tee” [fitting] in the line that supplies all three hydraulic reservoirs thereby bypassing the [pressurization] manifold completely and probably over-pressurizing the reservoirs. The Blue system pneumatic supply line (going to the hydraulic reservoir) was connected to a “union” [fitting], which is the manifold supply connection from the left engine thereby never supplying pneumatic pressure to the Blue reservoir. So the lines were criss-crossed. Both “B” nuts will fit on either connection and there is plenty of room for the lines to cross and not chaff on anything. It appeared that neither line had been replaced….

When an Airbus comes into the hangar, a Low-Pressure Check of each Green, Yellow and Blue hydraulic reservoir’s head pressure is performed using ground service air. Although the Blue reservoir’s head pressure was above the 22 PSI that sets off warnings in the cockpit, it was not possible to increase the head pressure by applying service air to see if the reservoir pressurization manifold was functioning. When the Blue head pressure did not respond, the thought was that the manifold was again at fault.

The aircraft had been flying for some time with the lines crossed, but since the Blue hydraulic reservoir head pressure never went below 22 PSI, no discrepancies were noted. Maintenance history showed the aircraft did have hydraulic issues with the Green and Yellow systems oozing hydraulic fluid, but those discrepancies were probably caused by high reservoir head pressures from the crossed pneumatic supply lines.
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May 2013
Report Intake:
Air Carrier/Air Taxi Pilots 4,063
General Aviation Pilots 1,115
Air Traffic Controllers 661
Cabin 358
Dispatcher 292
Mechanics 150
Military/Other 86
TOTAL 6,725
ASRS Alerts Issued:
Subject No. of Alerts
Aircraft or Aircraft Equipment 8
Airport Facility or Procedure 10
ATC Equipment or Procedure 5
TOTAL 23
Special Studies
Wake Vortex Encounter Study
ASRS, in cooperation with the FAA, is gathering reports of incidents that occurred while pilots were utilizing weather or AIS information in the cockpit obtained via data link on the ground or in the air. Learn more » Read the Interim Report »
Meteorlogical and Aeronautical Information Services Data Link and Application Study
In cooperation with the FAA, ASRS is conducting an ongoing study on wake vortex incidents, enroute and terminal, that occurred within the United States. Learn more »
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NOTE TO READERS:     Indicates an ASRS report narrative    [   ]  Indicates clarification made by ASRS
A Monthly Safety Bulletin from The Office of the NASA Aviation Safety Reporting System
Issue 402





NASA Aviation Safety Reporting System | P.O. Box 189 | Moffett Field | CA | 94035-0189

CALLBACK 401 - June 2013


CALLBACK From the NASA Aviation Safety Reporting System
Issue 401
June 2013
RNAV Standard Terminal Arrival Route (STAR) Issues
According to the Aeronautical Information Manual (AIM) Chapter 5, Section 4 (Arrival Procedures), a STAR is an ATC coded IFR arrival route established for application to arriving IFR aircraft destined for certain airports. RNAV STAR/Flight Management System Procedures (FMSP) for arrivals serve the same purpose but are only used by aircraft equipped with FMS or GPS. The purpose of both is to simplify clearance delivery procedures and facilitate transition between en route and instrument approach procedures.

A link to the full text of AIM Section 4 can be found at the end of this CALLBACK.

ASRS receives a significant number of reports every month related to difficulties with RNAV arrival procedures. Examples of reported issues include:
  • Complexity of RNAV Optimized Profile Descents (OPDs)
  • Flight Crew workload
  • Aircraft system compatibility or capability
  • ATC familiarity with aircraft performance and requirements
  • Procedure interruption and phraseology
The following ASRS report excerpts provide insight into some of the complexities surrounding RNAV arrival procedures and in particular, the problems associated with the “descend via” clearance.
IAD GIBBS1 RNAV Arrival
After having been cleared to “descend via” the GIBBS1 Arrival, the Flight Crew of an ERJ-170 was vectored off the arrival and uncertain as to their cleared altitude. Difficulty communicating with the busy Controller to clarify the altitude forced a level off at an intermediate altitude until a new clearance could be provided.
We were descending on the GIBBS1 RNAV into IAD between BBONE and KILMR when ATC assigned us a 020 heading for traffic. Our descent clearance was “descend via the GIBBS arrival” with no specific altitude given. I told my First Officer to ask ATC what altitude he wanted us at and we got no reply. After two more unsuccessful tries to get an answer (the Controller was busy), I leveled the aircraft at 11,000 feet which was the altitude for the next fix. We finally got a reply to our questions and were told to continue to descend to 6,000 feet.

As we had been cleared to “descend via” the STAR and, when vectored off of it, were no longer on the arrival, we had no guidance as to our cleared altitude. I’ve had this happen a couple times, with different altitudes given each time; some the same as the bottom altitude [on the STAR], some different. Anytime an aircraft has been given a “descend via” clearance and is later turned off the arrival, ATC needs to assign an altitude.
MEM FNCHR1
A B757 Flight Crew’s concern over their decision to descend to meet the STANI restriction was appropriate and, as they suggested, a clarification was in order. A more complete clearance might have included: a speed reduction to 290 knots, a descent to cross STANI at FL230 and, after STANI, “descend via” the FNCHR arrival.

Another item of interest was the First Officer’s comment, “During all this, the Controller was very busy with other traffic [since] many airplanes were getting vectored, given speed assignments and being rerouted with new STARS.” The purpose of the Optimum Profile Descent is to provide efficient descent profiles minimizing the need for communications and disruptions. Another intent is to reduce workload on ATC and Flight Crews. Reports such as this suggest that the procedures, as currently constructed, may not be fulfilling those intentions. In many instances the procedures are injecting uncertainty, increased workloads and greater risk of disruptions, deviations and potential separation issues.
We were flight planned for the LTOWN arrival but ATC rerouted us to ARG for the FNCHR Arrival. Approaching ARG from the east, we received radar vectors for spacing, which took us to the north and west of ARG at FL240 and 320 KIAS. At a point about 15 NM to the NW of STANI, we received the following clearance from ATC, “Cleared direct to STANI, ‘descend via’ the FNCHR1 Arrival.”

After we executed the new route in the FMC we noted the 290 knot restriction, which was appropriate at STANI, had not been programmed. This was because we did not cross ARG (the point prior on the arrival where the restriction was charted). Thinking we had to be at 290 knots, the Pilot Flying “speed intervened” while the Pilot Monitoring (PM) made the adjustment in the FMS. PM set 4,000 feet in the altitude window so as to descend via the FNCHR arrival. The airplane began an immediate descent to make the “at or below FL230” restriction at STANI. This is where I believe an error was made. At the time we left FL240, we were within 10 miles to the northwest of STANI, but not actually on the FNCHR arrival.

The ATC clearance was incomplete. We should have been given more guidance with regard to altitude. Either a clearance to descend to FL230 or a crossing restriction at STANI would have been appropriate.
From the First Officer’s report on the same incident:
We crossed STANI below FL230 and at 290 knots. The problem we believe we made is that we weren’t on a published portion of the approach, so therefore we departed an assigned altitude of FL240 to meet the STANI restriction. We should have clarified our clearance with ATC, whether to cross STANI at FL230 or FL240 and at what airspeed. I initially thought he wanted us to go direct to STANI and descend via the FNCHR, meeting the first restriction at STANI, but then we started to doubt that that was the clearance and thought perhaps he wanted us to proceed to STANI, cross it at FL240 and then “descend via.” A simple clarification would have solved this issue.

During all this, the Controller was very busy with other traffic as many airplanes were getting vectored, assigned speeds and rerouted with new STARS.
DCA TRUPS1
The Flight Crew of a CRJ-200, cleared to “descend via” the TRUPS1 Arrival, was understandably confused when given a heading change and then told to “continue” the arrival. The First Officer was the Pilot Flying and provides the first report on the incident.
We were cleared to “descend via” the TRUPS1 Arrival and a second Controller had cleared us to continue the arrival via the Runway 19 transition. Prior to reaching FRDMM waypoint, the Controller told us to depart FRDMM heading 120 which seemed excessive. The [crossing] restriction at FRDMM is 8,000 feet. The Pilot Not Flying queried the Controller regarding the heading, but due to congestion he couldn’t get a word in edgewise. Finally, the Controller issued new instructions to continue on the arrival. We were now at 8,000 feet and were past FRDMM [and were descending to comply with] the next crossing restriction of 6,000 feet [at STAND].

Shortly thereafter, the Controller issued another heading change and took us off the arrival. Seconds prior, when [we were] on the arrival, we had continued our descent. I asked the Captain to ask for clarification the Controller replied that we were told to “continue on” the arrival and not to “descend via” the arrival. We quickly returned to 8,000 feet and were cleared for the River Visual shortly thereafter.

The instructions were confusing at best. We were given a heading and, when we asked to confirm the heading, the response was changed to “stay on the arrival.” If the Controller had said, “Stay on the arrival; maintain 8,000” the confusion would not have occurred.
From the Captain’s report on the same incident:
After crossing FRDMM, we started to descend to 6,000 feet per the STAR and at the same time the Controller issued a heading change. I asked the First Officer if we should continue the descent since ATC just took us off the arrival and shortly after ATC asked us if we were still at 8,000 feet. I told him we were returning to 8,000 feet but thought we were still cleared to descend [as previously cleared] “via” the arrival. He explained that our new instructions were to “continue,” not to “descend via” the arrival.
PHX GEELA4
A Controller report highlights the confusion that can occur when runway “transition” clearances are given in conjunction with RNAV arrivals.
It was a busy arrival push into PHX this morning. With the GEELA4 RNAV arrival there are quite a few more transmissions that need to be made to ensure the pilot will do what we need him to do. If the pilot is to “descend via” the arrival, well that’s a straight forward clearance. When we have to vector the aircraft for sequencing, the phraseology to put the aircraft back on the arrival is very confusing. An A320 was issued a clearance to cross GEELA at and maintain 12,000 feet and 250 knots. The pilot read this back correctly. The pilot was then issued, “Cleared for the GEELA4 Arrival, Runway 7R transition.” At no point was a “descend via” clearance given or read back. The aircraft then called PHX Approach and said he was descending “via” the arrival.

We need to come up with some type of phraseology that will allow us to clear the aircraft for the arrival and transition without the pilot thinking he is cleared to “descend via” the arrival. It seems the pilots are associating the runway transition with a “descend via” clearance. Maybe we should give the runway transition on initial check in, if that is legal.
The complete AIM Section 4 Arrival Procedures can be found at: http://www.faa.gov/air_traffic/publications/ atpubs/aim/aim0504.html
Check Out
ASRS Safety Topics!
ASRS Database Report Sets each consist of 50 de-identified ASRS Database records relevant to topics of interest to the aviation community.  View/Download Report Sets »
CALLBACK Issue 401
 Download PDF & Print
 View HTML
ASRS Online Resources
 CALLBACK Previous Issues
 Report to ASRS
 Search ASRS Database
 ASRS Homepage
Subscribe to CALLBACK for FREE!
Forward to a Friend
Contact the Editor
April 2013
Report Intake:
Air Carrier/Air Taxi Pilots 4,635
General Aviation Pilots 1,225
Air Traffic Controllers 826
Cabin 363
Mechanics 298
Dispatcher 164
Military/Other 41
TOTAL 7,552
ASRS Alerts Issued:
Subject No. of Alerts
Aircraft or Aircraft Equipment 7
Airport Facility or Procedure 2
ATC Equipment or Procedure 9
TOTAL 18
Special Studies
Meteorlogical and Aeronautical Information Services Data Link and Application Study
In cooperation with the FAA, ASRS is conducting an ongoing study on wake vortex incidents, enroute and terminal, that occurred within the United States. Learn more »
Wake Vortex Encounter Study
ASRS, in cooperation with the FAA, is gathering reports of incidents that occurred while pilots were utilizing weather or AIS information in the cockpit obtained via data link on the ground or in the air. Learn more » Read the Interim Report »
Subscribe to CALLBACK for FREE!
Forward to a Friend
Contact the Editor
Facebook
Share with Twitter
LinkedIn
Facebook - Like
NOTE TO READERS:     Indicates an ASRS report narrative    [   ]  Indicates clarification made by ASRS
A Monthly Safety Bulletin from The Office of the NASA Aviation Safety Reporting System
Issue 401




NASA Aviation Safety Reporting System | P.O. Box 189 | Moffett Field | CA | 94035-0189

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